Tuesday, March 25, 2014

Although we talked a lot in college about the "bio-psycho-social" approach to treatment, most of the focus was on the "psycho" and "social" components. In college I learned that, as a process, therapy is emotional, psychological, and interpersonal; there is nothing physical about it. There was a lot of discussion about emotions but never any mention of how emotions are actually experienced. I only later learned that at their core, emotions are physical experiences. They are literally felt on a physical level. And yet not once during my formal education and training was this discussed. Instead, we talked about emotions as if they exist in our minds.

Most of my patients are people who have experienced trauma in one form or another. It turns out that physical experience is especially important to the coneptualization of posttraumatic stress disorder and other trauma related syndromes. Most of my patients are plagued by intrusive memories of past trauma and have extreme physical reactions to anything associated with their traumatic experiences. Some of my patients have panic attacks, which are defined by a variety of unpleasant physical sensations to include heart palpitations, sweating, trembling, chest tightening, shortness of breath, nausea, dizziness, tingling, chills, etc. Almost all of my patients complain of being hyper-alert and physically unable to relax. So while my patients may come to me for help with psychological or emotional problems, their difficulties are also very physical in nature.

When exposed to a life-threatening event, we automatically enter "survival mode;" our brains instinctively activate the "fight or flight" response by stimulating the autonomic nervous system. This activation creates a number of physiological changes in the body. Some of these changes include increased heart and lung action, inhibition of stomach and upper intestinal tract so that digestion slows or stops, constriction or dilation of blood vessels, pupil dilation, relaxation of bladder, inhibition of salivation, increased blood flow to the muscles, increased muscle tension, and increased blood pressure. The purpose of the "fight or flight" response is to provide the body with increased strength and speed in preparation for fighting or fleeing. Once the fight or flight system is triggered, the body feels compelled to do one or the other - either fight or flee. If neither response is possible in a given situation, the fight or flight system becomes overwhelmed. The result, according to Herman, is that, "each component of the ordinary response to danger...tends to persist in an altered and exaggerated state long after the actual danger is over." This explains the physiological symptoms experienced by people with posttraumatic stress.

There is a growing body of research suggesting that unresolved physical reactions associated with trauma must be identified and experienced physically for healing to occur. This is particularly true for people who experience their physical sensations as intolerable and overwhelming. This describes a lot of my patients.

I would therefore like to incorporate aspects of physical experience into my work with patients on a regular basis. Thus far I have only managed to do this in a few small ways. When talking about emotions, for example, I ask patients to describe the physiological sensations associated with various feelings. Sometimes I ask patients to identify where in their bodies they feel a particular emotion. Patients frequently describe these requests as strange or odd. Most have never thought of emotions as phsycial sensations taking place in the body. I suspect this is the case not only for my patients but for most people in general.

I suspect there are a lot of people who are not particularly comfortable inside their bodies. How often do most of us tune in to our internal body sensations? We live in our bodies yet we rarely listen to them. Experience tells me this is particularly true for men, who are often socialized to believe that displays of emotion are not masculine.

To be honest, "body centered" psychotherapy has always seemed too "touchy feely" for my taste. I've heard colleagues describe it as "hokey" and "froo froo." Some clinicians don't see it as "real" therapy.

Every therapist has his or her own personal "style" of therapy. Whether or not we adopt an unfamiliar technique depends a lot on how well it fits with our pre-existing therapy style. We choose techniques that feel natural to us. It's easy, however, to become too comfortable. When a clinician considers a new technique the primary concern should be potential patient benefit. If a certain tool or technique might be useful we should try it, even if it makes us uncomfortable. And so, in the coming weeks I hope to step outside of my comfort zone a little bit. I'll let you know how it goes.

Tuesday, March 18, 2014

One of the primary reasons I went into the mental health field was to help people, yet there were times early on when I wasn't sure I was accomplishing this goal. I used to spend a lot of time worrying about this. I worried about it so much, in fact, that it became a distraction. I began to dread seeing those patients who didn't seem to improve. They made me feel helpless and ineffective. I eventually started to dread going to work altogether. I didn't want to see patients at all anymore.

I considered a career change. In search of guidance, I even completed a few online career assessments. To my chagrin, every assessment suggested "therapist," "counselor," or "social worker" as good career choices for me.

I became depressed. I hated my job but felt I'd invested too much in my education and training to do anything else. And honestly, I couldn't think of anything else I wanted to do. I started counting the years until retirement but that made me even more depressed: I had at least forty years to go. How was I going to make it?

And so obviously something had to give. I did a lot of soul-searching, a lot of reading, and some self-help exercises. At some point it occurred to me to stop pressuring myself to "make people better" and instead try to focus on just being present with my patients. I decided to simply do the best I could with patients, regardless of the outcome. I made a sincere effort not to take it personally when a patient didn't improve. "You can't help everyone," I told myself. "Just do the best you can."

Work became more tolerable as a result of these changes. I learned to accept that there will always be patients who don't get better. There are lots of reasons for this, many of which have nothing to do with my ability as a therapist.

Now fast forward. I am nine years into my career. As a therapist, I am more genuine and more engaged with my patients than I was early on. I don't spend much time thinking about how helpful I am...it's a slippery slope and I don't want to start sliding. I just do my job the best I can and hope some people benefit from it.

Last week, I had a very rewarding experience. Our clinic runs a two week therapy group for active duty service members who have experienced some sort of combat trauma. A former patient of mine sometimes speaks to the group about his own experiences with trauma and its aftermath. I know he does this but I've never had the chance to sit in on one of these talks. Last week the opportunity arose.

My patient walked to the front of the room and introduced himself. He then turned and pointed at me. "The reason I'm here today is because of that woman right there." I was a little embarrassed when everyone turned to look at me. My patient continued. He talked about being in Afghanistan and about the difficulties he encountered there. He talked about coming back home and the problems he started having. He related his attempts to seek help, the first of which was disheartening. Finally, he talked about coming to our clinic and starting therapy with me.

My patient shared what he learned in therapy and identified what he found most helpful. He shared things I'd said and insights he'd achieved as a result. He seemed to remember everything we'd ever discussed. I, on the other hand, had forgotten what we'd talked about until I heard him speak.

It's not that I don't think about patients after they've moved on from therapy. Often I recall a specific patient and think to myself, "I wonder how he/she is doing now." I have never, however, remembered a patient and thought, "Wow, I really did a great job helping him/her." It's just not something I do, primarily for the reasons I mentioned earlier. When my former patient talked about the work we did in therapy it was almost like he was talking about some other therapist. It wasn't until later that I said to myself, "He was talking about me. I did that." And it felt really good to know that I helped.

Tuesday, March 11, 2014

Over the past couple of months I've expressed frustration about how conflict is handled in my marriage. Specifically, I've said I feel like I automatically get blamed when something goes wrong. I started doing some research because I wanted advice on how to deal with this effectively. I wanted my husband and I to learn to resolve conflict constructively.

Unfortunately, I didn't find the kind of advice I was looking for. While a lot of research has been done on conflict there was very little about how to respond to being verbally attacked and blamed. I did, however, discover a few helpful tips: Avoid responding to negative emotion with negative emotion; this only escalates the conflict. Express empathy (e.g., "I can see you are feeling hurt and angry"). And above all, try to remain calm.

This is good advice but it seems to be asking a lot. It is very difficult to remain calm when someone you love criticizes your very character and blames you for problems you didn't cause. When attacked, most people automatically become defensive. We quite naturally want to protect ourselves. A range of emotions are triggered, from fear to sadness to anger. In the face of this emotional torrent, rational thought and clear reasoning are severely compromised.

Not that I'm a complete hothead. There have been times my husband blamed or criticized me that I initially remained calm. In what seemed like a calm (but firm) voice I have replied, "Please stop blaming me." I said things like, "It doesn't matter whose fault it is," "If one of us 'wins' the other loses. That means the relationship loses," and "Let's focus on solving the problem, not on blaming each other." My composure gradually evaporated, however, when my attempts were met with continued blame and criticism.

It occurred to me that it might be easier to remain calm and express empathy if I could understand what was motivating my husband's behavior. You see, my husband is essentially a good man so I assumed his intent was not malicious. Maybe there was some underlying reason for his hostility during conflict.

And so I set out to learn about "conflict behaviors." My initial findings reinforced what I already knew: defensiveness and hostility during conflict is associated with high levels of "marital distress" and increased likelihood of divorce. Nobody had to tell me this. Each time a conflict went unresolved I felt a little more hopeless than the time before. A sense of distance arose in my marriage that had not been there before. For a marriage to work there must be away to resolve conflict.

I then learned that "aggressive denial of responsibility" (e.g., criticism, blaming) is employed most frequently by people with fragile and/or unstable self-esteem. I read about "contingent" self-esteem, whereby one's sense of self-worth is dependent upon maintaining certain self-imposed standards. (What if those standards include "always being right" or "never losing an argument?" If that were the case I was completely screwed)!

"Conflict behavior" is also related to "attachment style." Briefly, attachment style as a concept comes from attachment theory. Attachment theory states that an infant's relationship with his primary caregiver becomes a template for his interpersonal relationships throughout life. A healthy, secure infant-caregiver relationship facilitates "normal" social and emotional development. Problems in the infant-caregiver relationship disrupt social and emotional development. Inconsistent availability and/or responsiveness to infant needs by the caregiver leads to the development of an anxious or ambivalent attachment style. The defining feature of this attachment style is anxiety over abandonment. Adults with an anxious/ambivalent attachment style have a higher tendency than others to display hostility during conflict, to include the use of blaming, threatening, and other verbal aggression. When compared to adults with secure attachment, they show greater attempts to dominate conflict discussion.

My research led me to a tentative conclusion: "defensive hostility," "criticism," "aggressive denial of responsibility," and similar "conflict escalating behaviors" stem from underlying insecurities. (Incidentally, none of the research seems to suggest such behaviors stem primarily from "being an asshole." So that's good news). It is not immediately clear to me how to use this information. Assuming my conclusion is accurate, my husband is unlikely to ever acknowledge said insecurities, perhaps not even to himself. But perhaps just being aware will arouse my compassion in the midst of conflict. Maybe seeing criticism as motivated by fear and anxiety will help me to take it less personally.

Tuesday, March 4, 2014

I am not a fan of meetings. They always seem to drag on forever. Conversation tends to stray from the intended topic. I do okay if I have something to read or a crossword puzzle to do. This doesn't work very well in small group meetings, however. When there are only four or five people in the room it's harder to hide the fact that you're doing something completely unrelated and are not paying attention to what's being said. In these types of meetings I end up talking too much in an effort to stay engaged.

It's always been difficult for me to just sit quietly and listen to someone talk for extended periods of time. You may recall that I have narcolepsy; extended periods of inactivity tend to put me to sleep, literally. In college, I used to read and take notes during lectures. It was actually easier for me to pay attention when I was simultaneously engaged in doing something else than it was for me to give my "undivided" attention.

Because I can't avoid meetings (which would definitely be my preference if given a choice) I try to cope with them the best I can. Since the strategy for paying attention I used in college worked well for me I naturally continued to use it when I joined the workforce. Unfortunately, this caused a lot of problems when I first started at my current job. My supervisor at the time made comments to others about how disrespectful it was of me to read during meetings and presentations. It was obvious to me (and to a lot of other people) that my supervisor did not like me very much. It wasn't until the comments he'd made got back to me that I understood why.

I decided it was in my best interest for my supervisor to like me. I started going out of my way to show I was paying attention in meetings. I participated and contributed way more than I wanted to. But it seemd to work. Over time, my supervisor gradually warmed up to me.

Something about me ...When I get excited about something (which isn't very often) I have a tendency to go overboard. I keep talking about it when I know I should shut up. I realize this is a personal flaw but I have a very difficult time controlling it. This sometimes happens in meetings at work. Because I feel compelled to engage (as I mentioned before) I go out of my way to participate in discussions. Occasionally something interesting comes up and I get excited about it. Because I'm excited I keep talking about it far longer than necessary. I'm sure this annoys people; it annoys me. On the other hand, everyone has flaws. Most of my coworkers know me well enough to realize my intentions are good.

But apparently this is not always the case. The other day my boss (not the same supervisor I mentioned earlier) came to my office. (I absolutely hate it when this happens because it's never a good thing). She wanted to tell me that one of my colleagues who'd attended a meeting the week before was very upset because I'd interrupted him. She was of the opinion that he could have easily handled the problem at the meeting by simply telling me to let him finish speaking. She didn't understand why he felt the need to complain to someone else (who then went to her for feedback). Nevertheless, she advised me to be mindful of this in the future.

I checked my email later that day. I noticed I'd received an email from the colleague who had complained about me. I opened it. The email was brief. He wanted to talk to me about "something that happened at the meeting last week" and wanted to know when I would be available.

At this point I was annoyed. Okay, so maybe I was already a little annoyed but now I was irritated. It seemed far too much was being made over a very minor incident. This guy's complaint had already gotten me scolded by my boss. Now I had to schedule a time for him to call and chastise me?

I didn't respond right away. Actually, I considered not responding at all. The more I thought about it the more pissed off I became. My mind went back and forth with itself. Was I being too defensive? Was I just upset because I'd been criticized? I know I don't like criticism -- nodbody does. But I make a conscious effort to try to accept it when it's warranted, no matter how defensive I feel.

Honestly though, I wasn't even sure it was the criticism itself I was upset about. Okay, so I interuppted him. I know I have a habit of doing this when I get excited. I know it's a problem. It might sting a little to have someone else point it out but it's probably the best thing to help me break the habit.

The thing is, the guy who complained hadn't pointed it out to me. Instead, the chain of events went something like this: 1. I unintentionally offend a colleague at a meeting. I do not know I have offended him. He says nothing about being offended. 2. He apparently pulls my coworker aside after the meeting. He tells her he is offended. He says if I am going to interrupt him then he is not going to come to the meetings anymore. He asks her to speak to me about it. 3. My coworker doesn't feel comfortable speaking to me about it. Instead, she goes to our boss for advice. My boss says she should advise the offended colleague to simply tell me he was offended. She was sure I didn't mean to offend him and would promptly apologize for doing so. 4. My coworker communicates this message to the offended colleague. 5. In the meantime, my boss comes in to my office to talk to me about another issue. She also mentions that a colleague was offended that I'd interrupted him. She asked me to be mindful of this in the future. I say okay. 6. The offended colleague receives the feedback advising him to address his concern with me himself. He sends me an email to schedule a time to talk about "something that happened in the meeting last week." You know the rest.

I was convinced that my offended colleague had not handled the situation correctly. There are a lot of un-offensive, socially acceptable ways to say, "Please don't interrupt me" or "Please let me finish speaking." If he'd said something, I probably would have apologized right then and shut up. No big deal. Still, I wasn't sure if this was a valid reason for me to be upset.

I ended up seeking advice from a trusted coworker. She agreed that the whole thing had been blown way out of proportion. She suggested I reply to the offended colleague's email telling him my boss had already spoken to me about the issue and apologizing for interrupting him. So that's exactly what I did.

He emailed a response. He accepted my apology. He also suggested that, in the future, I don't give any feedback unless someone asks for it. Ha!

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About Me

I'm a Licensed Clinicial Social Worker (i.e., a "sit on my couch and tell me your problems" therapist). I'm also a woman just like any other woman, with the same wants, needs, problems, thoughts, feelings, etc. Being a therapist gives me a unique perspective though -- I'm more self-aware than your average person and I understand why I do almost everything I do. (If I don't know why I usually set off on yet another journey to better understand myself). The title of my blog is "This is Me" but my hope is that it's not just about me -- it's about you too. I hope that you will find a little of yourself in my words and that in seeking to better understand myself others will have the opportunity to better understand themselves as well.